Medicare clarifies 'incident to' billing process

August 1, 2008

The bottom line is that if the physician or other qualified provider, such as a physician assistant or a nurse practitioner, is not in the office when a service is provided, the service cannot be charged to Medicare

We have discussed the various strict rules that apply to "incident to" billing in the past. Medicare requires that the physician be immediately available during the procedure for any charge to be billed. Under Medicare rules, being "immediately available" means that the physician is in the office suite at the time the service was provided.

The bottom line is that if the physician or other qualified provider, such as a physician assistant or a nurse practitioner, is not in the office when a service is provided, the service cannot be charged to Medicare. In the example of the LHRH injection, in addition to the "no charge for the injection" policy, you cannot charge for the drug. Single practitioners or solo practitioners have had to (or should have had to) change the way they practice to be sure that all services are provided while they are in the office, as opposed to when they are on rounds at the hospital, on the golf course, or out of town.

Shift in practice procedures

Dr. Painter offers this personal example: Because of the consulting I was doing in coding and reimbursement, I had left my group practice in Grand Junction, CO, and was in solo practice in Glenwood Springs, CO, at the time the new Medicare payment system was implemented, including the new "incident to" rules. My previous practice was organized so that all injections, urodynamics, and the other services that could be delegated to my nurse were performed in the office while I was in surgery.

However, when the rules changed, I had to change the way I practiced. I had to hire additional part-time personnel to work when I was in the office. Also, I didn't need as many bodies in the office when I was in surgery. So I changed my employees and my way of practice to accommodate the new law.

For individuals in group practice, it is important to be sure that all services provided are charged as if they had been performed by the physician who is in the office at the time the service is provided, not the physician who ordered it or the physician by whom the patient was seen. Therefore, if Dr. A is in the office and Dr. B's patient comes in to the office for urodynamics, then the technical component (procedure codes with –TC modifier) is charged as if the test had been performed by Dr. A on that date. If Dr. B then sees the patient and reads the urodynamics the next day, Dr. B would charge the professional component of the same urodynamic codes (code with the –26 modifier).

As a second example, a patient comes in to the office for an LHRH injection on the day that Dr. A is in the office. Although he is Dr. B's patient, the injection and the LHRH should be charged as if it had been performed by Dr. A.

When a solo practitioner who practices without a physician assistant (PA) or nurse practitioner (NP) goes on vacation, then the office should make no charges while the physician is gone.

Services provided to a patient by a PA or NP when the urologist is in the office can be charged "incident to." In other words, those services can be charged as if the physician had provided the service. However, if there is no physician in the office, the PA or NP can charge for services provided under her billing number because she is considered a "qualified provider." If the nurse or medical assistant inserts a catheter while the PA or NP is in the office and there is no urologist present, that catheterization would be charged as if it had been performed by the PA or NP.

In summary, here are the rules:

Note that private payer rules may vary. One payer, for example, defines "immediately available" as being within 20 miles of the office and available by phone.

Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook. Mark Painter is CEO of PRS Urology SC in Denver.

Disclaimer: The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.